“What about them implant things?”

Today’s blog post is going to be an overview of dental implants. I won’t go too much into specifics of types, the science etc because it’s a bit irrelevant, many boffins in many Scandinavian labs have done all the work for us and also, I  have no idea what half of the publications related to said science are on about.

I will split the topic into 2, what they are and what they can be used fo and in whom, then will do a part 2 explaining what is involved in their placement, aftercare, lifespan etc so stay tuned for that!

Shall we begin? Good.

What are they?

The Association of Dental Implantology UK (ADI) define implants as “a substitute for a natural root and commonly it is screw or cylinder shaped”. The actual object called the "dental implant" refers to the bit that is in the bone. Other components can be added/ attached to make the implant functional, for example, something called an abutment can be screwed on top, which passes through the gum and allows prosthetic (fake) teeth to be attached. See helpful pictures below.

Why would you need them?

So, you find yourself in the situation where you are either already missing, or are about to lose either 1 tooth e.g. you got caught in a drunken brawl, you ate too many sweets or in fact several teeth, for instance due to dental disease or following trauma (often horse related) or after removal of tumours etc. 

Placement of implants after cancer surgery is much more involved because not only are the teeth often missing, but the disgusting thing takes most of either one or both jaw bones with it and so extensive rebuilding is necessary before implants can be placed therefore making it much more complicated and beyond my limited realm of knowledge and so we shall stick to the “I haven’t brushed my teeth for 20 years and would now like you to fix it for me” causes of tooth loss.

How do they work and what can they be used for?

This seems a fairly obvious question however there is a lot of confusion of what implants can do. They are the closest thing to a natural tooth that can be provided by a dentist however they have several limitations. They can be used to replace individual lost teeth, in the majority of cases this is front teeth.

There is a lot of panic about losing and replacing of back teeth. Obviously if you have one of those smiles that shows every single tooth in your mouth and beyond, or have one of those laughs where you can see your epiglottis then the concern about missing a tooth is understandable. Fortunately most people don’t have this problem and so if you lose a molar tooth, there is actually no need to replace it. Especially with something that costs a minimum of 2 grand.

***As a side note if you come across one of those adverts promising 15 implants for the cost of a Mars bar, I would stay well away. I would consider dental implants in the same way you would think about other implants – hip replacements, breast implants etc and if you wouldn’t go to a rat infested converted house to have those done on the cheap, then you shouldn’t have your teeth done in the same situation. I think because they’re teeth people believe that the same standards are care aren’t necessary, only takes 5 years to be a dentist and that, surely my beautician could do it? The answer is no. Obviously. Mainly because if something goes wrong, its’ your jaw and your head. There is limited bone and so any infection caused by dodgy placement (bearing in mind there is a risk of infection even under pristine surgical conditions and a skilled operator) means that you are at risk of losing significant portions of your jaw bone and at this point, we can’t fix it. Mini rant over. Let’s continue

The only feasible reason for replacing a missing back tooth is to stop over-eruption of the opposing tooth, that is to say when the tooth that is biting against the one that is lost grows out of the gum and into the space. It is a very rare case that a tooth in the mouth ONLY comes into contact with 1 other tooth when biting, usually they touch 2 or 3 depending how you bite and for this reason usually over-eruption won’t occur.

Let’s see if a picture helps…

 Over-eruption means that the bit of the tooth that usually sits under the gum line is now exposed to the mouth. In terms of potential consequences this can look a bit unsightly, but again it would depend on your smile and what is shown. If you only see it in the mirror when you’re looking at a demented angle whilst stretching out your cheek then it really won’t affect your life. The other potential problem is that the bit of tooth under the gum line doesn’t have the protective enamel layer and so can be sensitive but again this can be dealt with in other ways that doesn’t involve damaging any teeth by placing bridges or burning a hole in your wallet.

Implants can also be used to replace multiple teeth either as a way of acting as an anchor for a bridge, which thus will replace 2 teeth, or to have several implants to more effectively hold in a denture.

Implants are NOT used to replace every tooth in the mouth. If you have no teeth left, then you need a denture. End of. The stabilisation of a denture CAN be improved by implants.

I emphasise word can for the following reasons. Fortunately some clever people have done some research so I can insert that now…

Assunção et al found that “Although the stability of the mandibular (lower) implant-retained denture was enhanced compared to a conventional denture, the quality of life and satisfaction levels were similar for both the groups.” i.e. the groups of people with and without implants felt equally happy (or in fact unhappy) with their dentures.

Allen et al found that “Subjects who received implants that replaced conventional complete dentures reported significant improvement after treatment, as did subjects who requested conventional replacement dentures” i.e. simply having some sort of denture was more important/life changing than having implants to hold a denture in.

Basically, implants are not the be all and end all of tooth replacement.

So, that’s what they can be used for, how about what they actually are.

	For this reason, one of the risks of having implants placed is that if they fail, it is often due to damage to the bone surrounding the implant rather than the implant itself as the metal implant is far stronger than the bone it is encased in and in a fight, the weaker one loses. This is the same reason by post crowns fail – the post is stronger than the tooth it is stuck in, so rather than the post breaking, the tooth does instead. I will go into this more in the second part of this blog. Multiple implants to stabilise dentures work in a similar way but takes slightly more careful assessment as it is not a case of plonking an implant in where a tooth has come out. The position and placement of the implants in order to best retain a denture has to be worked out and will be different in every person.

  

As you can see from the above pictures, this particular patient has 4 implants. They can be left as the implants alone onto which the denture clips. Or the implants can be connected with a bar and the denture clips onto this. Sometimes fewer implants will be placed etc etc and this will all be decided by the implant-surgeon.

Below you can see how denture clips into the implants. This particular case does not have a bar whereas the one above does.

In the final bit of this blog post I will quickly go over who is not suitable for implants. Of course you will most likely be able to track down someone somewhere who will place the implants without asking questions. As I said earlier, if you like taking risks with your health and in fact life, go ahead. If not, go to someone who actually knows what they’re doing who will tell you the following.

Contraindication	Why
Smoking	Smoking reduces blood circulation in the mouth and suppresses the immune response in the mouth, what this means is that healing in smokers is crap. As healing is necessary for implants to work (as the bone needs to fuse around the implants) it is highly reduced in smokers. Thus infections and fusing of the implants is highly reduced. You may also experience more pain from the procedure and this pain could last for longer. It is also possible that the implant will never heal and this could leave you in constant pain, resulting in the removal of the implant. Finally, long-term smoking affects how dense the bone is meaning that finding suitable strong enough jaw bone is more difficult.
High alcohol use	Alcohol, like smoking, seriously affects healing and thus can lead to implant failure.
Gum disease	Number one, gum disease can destroy bone. No bone = no implants. Simples. Even if enough bone is found to put an implant in the first place, gum disease will inevitably lead to its failure through the same bone destruction.
Clenching and Grinding teeth	As briefly mentioned above, the implants are not natural shock absorbers like teeth are and so any excess force, like clenching and grinding of the teeth, can damage the crown on top of the implant and potentially the base of the implant as well just as clenching and grinding can damage natural roots.
Weakened Immune System	Implant placement requires an operation. While it is a relatively minor operation, any reduction to the immune system normal responses can lead to infection. Weakened immunity can occur naturally with age, due to chemotherapy, AIDs, cancer, steroid therapy, medication following transplants, Diabetes etc. Of course this will be discussed during consultation and whilst having these conditions/taking those meds does not completely rule you out from having implants, certain modifications to treatment might have to be made
Bisphosphonate Medication	Bisphosphonates are a type of medication taken mostly for osteoporosis, but also for conditions such as Paget’s disease, bone cancers, metastatic cancers. They basically alter the way that bone heals and for that reason, anything that “damages” the bone in patients taking these medications can lead to devastating infection.
Unsuitable bone	For example very thin bone. While it is possible to bone graft, move the sinus to create more space etc this is far more extensive treatment. This is particularly irritating when people come in, you tell them they need a denture, or that we cannot fix their dentures to make them like normal teeth. The automatic response of the patient being “what about them implants?”. If you have enough teeth missing to need a denture, you need a denture. If your dentures drop out because you have no bone left, you can’t have implants without a whole tonne of extra surgery.

.

So that’s all for today folks!!!

Feel free to ask any questions and remember to check back in a couple of weeks for details of exactly what is involved in implant placement and sadly, things that can go wrong!!

References and that..

Allen, McMillan, Walshaw,  A patient-based assessment of implant-stabilized and conventional complete dentures The Journal of Prosthetic Dentistr Volume 85, Issue 2, February 2001, Pages 141–147

Assunção WG, Zardo GG, Delben JA, Barão VA. Comparing the efficacy of mandibular implant-retained overdentures and conventional dentures among elderly edentulous patients: satisfaction and quality of life. Gerodontology. 2007 Dec;24(4):235-8.

Chee & Jivraj  Failures in implant dentistry British Dental Journal 202, 123 - 129 (2007) 

http://www.adi.org.uk/public/implant/whatis.htm

http://www.clydedental.com/dental-implants-glasgow.html

http://www.philipfriel.com/implant-retained-dentures-gallery.html

http://kumarandentalclinic.com/Missing%20Tooth.htm
http://www.philipfriel.com/implant-retained-dentures-gallery.html

http://en.wikipedia.org/wiki/Dental_implant

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Wisdom twooth

Hello all.

If you have returned for the second instalment of my wisdom tooth rant then I thank you! I realise the last one was a bit of a slog but hopefully it provided some basic information about the problems wisdom teeth cause.

I discussed pericoronitis last time, which is the most common problem wisdom teeth cause. I also briefly mentioned that if you rocked up to your dentist, or worse, the dental hospital, demanding extraction (whipping out) of your wisdom teeth because they don’t look very nice, they are the cause of all your life problems (failure of your marriage, loss of job etc) then sadly you will be met by a wall of silence and handed a “bye bye” discharge letter.

Unfortunately, as with most things, there are risks to taking out all teeth. Wisdom teeth are particularly troublesome (to put it mildly, I would quite frankly say they are a pain in the arse) to take out.  This is mostly because of the position right at the back of the mouth, or as mentioned before that they are literally wedged in place often below the gum line. They are also a bit of an anomaly. Whilst most teeth have a generally accepted anatomy, wisdom teeth are a law unto themselves, a bit like Miley Cyrus or Lady Gaga – you never know what you’re going to get from one day to the next. They can have 1-3 roots of different angles, either splayed out or fused together. They can be surrounded by bone, or even be fused to the jaw bone. Therefore, if we can avoid taking them out – much as we enjoy getting out our pneumatic drills and nail guns – if you don’t absolutely need them removing, you don’t get them extracted. Especially not by me.

The most important reason for why we are hesitant about taking wisdom teeth out however is due to unavoidable potential side effects, the most important being nerve damage.

In order to explain this I am sadly going to have to describe the process of extracting wisdom teeth in some detail. If you are at all squeamish, you may wish to skim over this bit.

Of course, if you have a fully erupted wisdom tooth, i.e. it is fully visible in the mouth just like all the other (normal, non-pain-in-the-arse-causing) teeth, then the procedure for taking it out is no different to other teeth.

However when the tooth is partially erupted, or unerupted, it is surrounded by bone and there is very little/no tooth to grab hold of with our highly advanced sci-fi (not) forceps. In this case we have to do something called “minor oral surgery”. As opposed to major oral surgery which I imagine entails something similar to beheading and fortunately not performed by any of us toothworkers. Well, not intentionally anyway.

Minor oral surgery for wisdom teeth

As the wisdom tooth is surrounded by bone, in order to take it out, we have to remove some of this bone, and the only way to do this is peel back (sorry, I desperately consulted several thesauruses for a better way of phrasing this but this genuinely is the best way of describing what we do) the gum and then drill away some of the bone in the same way that we drill to do a filling.

Before you go into panic mode, the important thing to remember is that the only difference between a “normal” extraction and this method is that we directly visualise the roots of the teeth that we are trying to take out. In some ways this is actually easier and often means that less “force” is required to take the teeth out as we can get a better leverage and see exactly what we are working with – i.e. 3 roots, 2 roots, fused roots etc.

The same amount of anaesthetic (if not slightly more because we often book longer for this minor oral surgery appointments than we do for regular extractions) is used, and the only difference you will actually be aware of is the noise/vibration that occurs when removing bone, and the fact that you will have some stitches in place afterwards.

So here goes.

How to (surgically) take out a wisdom tooth for dummies.

1)    2 or 3 cuts are made in the gum. Again, please remember you will be completely numb for this, so you will feel that we are there/pressure but not pain.

2)    The wisdom tooth will then be hidden behind a layer of bone.

Sadly, Google seems to want to terrify people into never attending a dentist ever again and thus most pictures I could locate were not appropriate for this blog, unless I want to do myself out of employment of course.

 It is at this point that I suppose the most “risky” aspect of the extraction arises.

  

This nerve supplies sensation i.e. feeling for HALF the lower lip (the half being whichever side the tooth you are talking about is, i.e. right tooth, right half of lip), some of the skin of the cheek, and half of the lower teeth. It is important to mention that it does not provide motor or movement supply to these areas.

When extracting LOWER wisdom teeth damage can occur to this nerve. The wisdom tooth can be sitting on the nerve and when it gets wiggled out this can irritate the nerve. The roots can be wrapped around the nerve and on taking it out more damage can occur. Sometimes the tooth itself is not actually touching the nerve but in order to extract the tooth, bone has to be removed and this can cause damage to the nerve. See below. #freeadvertisingforthisguy

This means that following the extraction it will feel like you are still numb. Like when you have an injection before a filling for a lower tooth, that sensation will continue past the time when the anaesthetic wears off. There are various figures in the literature about 1) the chances of this damage happening and 2) whether or not the sensation comes back.  They estimate that there is around a 2% risk of damage occurring to this nerve during lower wisdom tooth extraction. Of course if you need an upper tooth out, this risk is irrelevant. In terms of whether this sensation will return, there is again debatable evidence. It is most common that the disturbance to feeling is temporary i.e. it will return, usually fully, however it is estimated that 0.6 to 2.2 percent of cases of people who lose sensation after wisdom tooth extraction will have this permanently.

What this means in terms of your daily life is that nothing will be visibly different either whilst your face is still, or if your face is moving. Your lip etc will move normally, it will just feel different i.e. numb or have a pins and needles sensation. It is however important to point out that there is a small chance that by leaving infection or pathologies (e.g. cysts) around wisdom teeth, the same nerve damage can occur but is much less predictable so it really is best to get them out in this case.  

Whilst we will always take an xray of the tooth to be extracted, and have a good idea of where the nerve is positioned, radiographs (x ray images) are only a 2D image of a 3D situation so the only really guaranteed information they can give us is “yes the tooth is close to the nerve” or “no the tooth is miles away”. Luckily some Hungarian oral surgeons have completed a study and summarise this nicely “radiography [i.e. taking and interpretation of x ray pictures] is an inadequate screening method for predicting IAN [inferior alveolar nerve] paraesthesia after mandibular [i.e. lower] third molar removal”

Back to the surgical bit….

3)    Following bone removal so that we can see the tooth,  it is then extracted. This is done in a number of ways but for the purposes of how much you need to know and what you will be aware of, at this point you will feel pressure and lots of wiggling of equipment from our part.

4)    Once the tooth is out, we will then replace the flap back over the area and place a couple of stiches to hold it in place. These will dissolve by themselves but you will of course be aware of them.

As with any extraction, you will be sore afterwards. As you can see, the procedure is slightly more involved than the normal, grab-it-pull-it-out technique that we can use on other teeth, so expect to feel a bit naf for a few days. Your dentist will give you lots of aftercare instructions and things to expect straight after you have gone through this and thus you won’t listen to a word so I will summarise.

1)    Pain, swelling.  I have lumped these 2 together because it is pretty much guaranteed that you will experience these. In terms of pain, the best medication to take is paracetamol and ibuprofen. You do not require codeine or in fact as I have been asked for on several occasions – ketamine. Please check that you are ok to take ibuprofen. It is one of a group of drugs called NSAID’s and can cause problems for certain asthma sufferers, people with kidney disease, stomach problems etc. Also, if you are already taking an anti-inflammatory medication e.g. for arthritis, back pain, then do not increase your dose.

Swelling will reach a maximum after 48 hours then begin to go down. You may also notice some bruising if it is a particularly difficult extraction. Expect the worse basically, then you will be pleasantly surprised.

2)    Bleeding. This is where people get confused. If you have the tooth “surgically” removed, the wound will be stitched. This can help reduce but not eliminate bleeding. If you do not have stitches, there will be some oozing of the area. The small amount of blood coming from the socket where the tooth was taken from, mixes with saliva and causes people to panic that they are bleeding out and have seconds to left to live without a transfusion.

We will usually give you some squares of gauze to take home with you. If you feel that the area is actually bleeding, i.e. when you spit out, it is red not just pink, then roll one of these gauze pieces up into a sausage and bite for 20 mins. If bleeding continues you need to return to your own dentist or go to A+E.

3)    Infection. When you cut yourself elsewhere on the body, in order for it to heal you want a scab to form. In the mouth it is a similar concept but you want a blood clot rather than a scab. If you do a gym session, lift heavy objects, raise your blood pressure in any number of ways, this will dislodge the clot and leave a gunky mess in the socket. Gunky mess = no healing. Similarly, if you decide to leave the dental surgery and have a fag, the same thing will occur. You will then come back crying to us in more pain than you were with the toothache, with something called “dry socket”.

Heat will also increase blood pressure, so don’t hold anything hot against the side of the face to try and ease discomfort because it will just make it worse in the long run.

If this does occur, go back to the dentist and we will place a dressing in. This works wonders but it tastes repulsive so let that be a warning to you.

4)    In terms of keeping the area clean, brush the other teeth as normal. SPIT DON’T RINSE FOR 24 HOURS. As above, if you rinse and swill around the mouth vigorously, you will dislodge the blood clot and end up in the above situation. For 24 hours just spit out any blood stained saliva you feel is building up. After 24 hours, start with some hot salt water mouthwashes. Get some hot water, fill a mug or a cup, add a teaspoon of salt, GENTLY swish this around your mouth and spit out until the cup of water is gone. If you don’t do this, you will get nice bits of your roast dinner, cereal etc building up in the socket which then I have to fish out. Usually before lunch. Please save me having to do this.

5)    If you have any concerns, please just ring your dentist. They can advise you, settle worries, and recommend you come in for a check if necessary.

Finally, just when you are wondering why the hell anyone would choose to do this to themselves, there are a number of myths surrounding extraction of wisdom teeth and why/when we take them out. For this I require the assistance of the wonderful people at the National Institute for Clinical Excellent (NICE) who provide helpful although thoroughly not-NICE guidance on a number of clinical topics.

Because of the aforementioned risks of taking wisdom teeth out – pain, bleeding, swelling, infection, nerve damage etc – we will try not to do it if we can. NICE in fact says that there is no reliable research to suggest that impacted wisdom teeth free from disease should be operated on.

They classify “disease” as decay which cannot be fixed by filling or root canal treatment, either because it has gone too far or because the tooth is at such an angle that we simply cannot treat it. Similarly, if it is causing damage to next door teeth, this is a valid reason for removal. Wisdom teeth are also deemed to be valid for “the bucket” if they are in the path of a cysts, tumour, or cancer which needs removal.

In terms of the aforementioned pericoronitis, NICE basically suggest it is a bit of an opinion based deicision. They state that “plaque formation is a risk factor but is not in itself an indication for surgery…The evidence suggests that a first episode of pericoronitis, unless particularly severe, should not be considered an indication for surgery. Second or subsequent episodes should be considered the appropriate indication for surgery”. I.e. unless you have been back to the dentist several times with this problem, and we can see that you have been trying to resolve the situation yourself by keeping it clean, you will not qualify to have the tooth taken out.

To finish, the common myth that eruption of wisdom teeth causes crowding of the other teeth. I was going to paraphrase this paragraph from oralhealthgroup.com but it just summaries the absolute ludicrousy that this concept presents.

“It is not possible for lower third molars, which develop in the…interior bone…with no firm support, to push 14 other teeth with roots implanted vertically like the pegs of a picket fence so that the incisors in the middle twist and overlap. Third molars do not possess sufficient force to move other teeth. They cannot cause crowding and overlapping of the incisors, and any such association is not causation.

This is also supported by a number of studies of high evidence level (i.e. they were conducted by the highest level of boffin). I have included some of these below with boffin-normal person translations:

1)    No statistically significant third molar presence-specific differences were recorded in the lower dental arch crowding between the groups with erupted and unerupted third molars. i.e. people with crowding were examined and among these people it was noted whether or not they had wisdom teeth present. The study found that the crowding was completely unrelated to the presence of 3^rd molars.

2)    The principal conclusion drawn from this randomized prospective study is that the removal of third molars to reduce or prevent late incisor crowding cannot be justified. Now us tooth workers love nothing more than whipping out teeth so this is a fairly significant finding. 

3)    The dental arches in the extraction group tended to be more crowded than in the group with complete dentitions. i.e. this study found that in cases where wisdom teeth had been extracted there was in fact MORE crowding. This is most likely a coincidence but just goes to show the lack of importance of wisdom teeth on crowding.

4)    This study has not been able to predict which patients should react favourably or unfavourably to removal of the third lower molars in cases of anticipated crowding. I.e. these guys haven’t got a clue.

In summary, if you are in pain from your wisdom tooth, get it out. Yes there are risks but there are also risks of leaving infection teeth in place.

As always, if I have terrified you and you wish to tell me this, or if you want any further explanation of any aspect, please feel free to comment on here, or follow me on twitter @smiles__better.

Ode to the boffins:

Forsberg Tooth size, spacing, and crowding in relation to eruption or impaction of third molars American Journal of Orthodontics and Dentofacial Orthopedics Volume 94, Issue 1, July 1988, Pages 57–62

Friedman The Prophylactic Extraction of Third Molars: A Public Health Hazard Am J Public Health. 2007 September; 97(9): 1554–1559.

Harradine NW, Pearson MH, Toth B. The effect of extraction of third molars on late lower incisor crowding: a randomized controlled trial. Br J Orthod. 1998 May;25(2):117-22.

Lindqvist, Extraction of third molars in cases of anticipated crowding in the lower jaw American Journal of Orthodontics Volume 81, Issue 2, February 1982, Pages 130–139

NICE guidelines: Guidance on the Extraction of Wisdom Teeth

Sidlauskas A, Trakiniene G. Effect of the lower third molars on the lower dental arch crowding. Stomatologija. 2006;8(3):80-4.

Szalma J The prognostic value of panoramic radiography of inferior alveolar nerve damage after mandibular third molar removal: retrospective study of 400 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2010 Feb;109(2):294-302. Epub 2009 Oct 20.

http://www.toothology.net/getmedia.asp?media_id=52

https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjo9-mQa2VBDEZbNbzcTjbxMicpvqb5XnVBMJ_C34e79_v2ZRRy1Z28ExsRew8DFROn8-Ost6eWxD4ViBgr7IL2VI2eRUlBvgnQraIjLtmNWrtHjoXBvj3BmjUzXc9ZH97MNXeqL4-TBH7T/s1600/Picture5.png

http://www.alanyadentalcenter.com/oral-surgery/

http://www.ryoungoms.com/procedures/bone-grafting/socket-preservation/

http://www.orthodontics.org/wisdom.htm

http://www.checkdent.com/en/videos/wisdom-tooth-extraction-210.html

http://dentalcarematters.com/tooth-extraction-aftercare-advice/

http://www.oralhealthgroup.com/news/inferior-alveolar-nerve-damage-during-removal-of-mandibular-third-molars/1000158840/

Oral How-giene

This may sound like a very broad and very obvious topic. Sadly over my relatively minimal tenure in the dental profession I have come across many abominations of the aforementioned topic.

The problem usually begins with a simple question: “so, how often a day do you brush your teeth”. At the beginning of my studies I believe my emphasis was on “a day” assuming that most people would abide by the twice a day brushing rule. Sadly these people were in the minority.

 I then reassessed my questioning technique and modified to “how often do you brush your teeth”. I was met frequently with, “errr I’d say around twice a week”.

Just to put this into some sort of context a have created a week-to-view calendar of this patient’s oral hygiene habits.

Again, just to emphasise the point this would involve, going to bed, waking up, going to bed, waking up, going to bed, waking up, going to bed and waking up WITHOUT CLEANING YOUR TEETH.

Of course there are many combinations of the above diary and I have just highlighted one, of course said patient may have a special gathering on a Wednesday so they may rummage behind the sofa and whip out their brushing implement (I avoid using the word toothbrush for reasons described later) for this exceptional event upping their weekly mouth cleaning total to 3.

I realise sadly I am a special breed of person who struggles to have a glass of water without feeling like my teeth are covered in fur, but surely this must feel AWFUL. What is often shocking is these people are in attendance of their dental appointment with a partner. Someone who presumably gets within a close vicinity of said mal-brusher. I will leave your mind to fill in the rest.

After realising that the majority of people neither brush twice daily, nor use a toothbrush I have modified my questioning to “so, what is your cleaning routine for your teeth” which usually gets me the response I am after.

I have also encountered a realm of instruments and methods used for cleaning teeth. From sticks (“Jesus used a stick so must be good enough for me”) to brushes which only could have been designed for horses.

As I have mentioned before, I am not sponsored by anyone or anything (I can’t imagine why) and so my advice comes not from a monetary fuelled avenue. Whilst I enjoy a gadget and thus use a Sonicare toothbrush, this was given to me free are charge during University when our young student minds were easily swayed by freebies. You can pick up toothbrushes for 9p. Yes that’s right, 9p. I just checked. Look. http://www.tesco.com/groceries/Product/Details/?id=256420940. They do pretty much the same job. Strangely enough saying this, I have only encountered one person who used cost as an excuse for not brushing.

A few of my personal favourite excuses, alongside those I have borrowed from other colleagues’ horrific reports are recorded below.

“I used to have great teeth but they wouldn’t let me take my electric toothbrush to jail”

“My previous dentist told me brushing damaged the gums so I don’t bother anymore”

“My gums bleed when I brush” This excuse isn't so comical and I will cover later on in another post.

“My brother flushed my toothbrush down the toilet” (which warrants the question how powerful is your toilet flush!?)

“My toothbrush broke”

“I get up very early and the sound of my electric toothbrush wakes up the kids”

Apparently the excuses don’t stop at the brushing implement itself.

“I just don’t like the taste of toothpaste”

"My dad took the toothbrush to work so I couldn't use it"

“I’m allergic to fluoride”

"No one told me I was supposed to clean my teeth"

“I don’t have time” – this is often said by a woman wearing make-up so thick that could only be removed using a wallpaper stripper

There are some people who get away with not adequately cleaning their teeth. Sadly the majority of poor mouth-cleaners are those who also believe losing a filling and leaving it for 5 years won’t cause any detrimental effect. Please refer to previous blog post for my feelings on this. These people of less-than-socially-acceptable plaque carriage are also the ones who enjoy the following rant:

“I don’t understand why my teeth are so rubbish. They just aren’t formed right I don’t think. When I was pregnant they just crumbled/I fell off a bike when I was 37 and they’ve never been right since/they just fell apart. My sister/brother/dog has lovely teeth and I just don’t understand why I’m so unlucky”.

Post-rant actual advice

1. Brush twice a day. Yes. Brush. With a toothbrush. If you use the right technique which any dentist or hygienist will be able to show you it doesn’t really matter whether you use a manual or electric toothbrush

• I personally feel electric toothbrushes are easier to use. You can’t apply too much pressure and for people with manual dexterity problems or who suffer from laziness it does the work for you. At this point I could insert various studies and "clinical trials" showing results of manual vs electric toothbrush contests. Sadly 99% of these are sponsored, conducted, altered and generally biased by the dental trade. I.e. Oral B pay for studies to be done about Oral B. Same for Sonicare etc etc. Therefore it is not wise to read to much into this. As a general guide, it is what feels comfortable to you. Some people despise sonic toothbrushes, I personally very much enjoy mine.
• If however you are going to venture into the world of dental gagettery, then I would recommend the following. Invest. This does not mean spending a fortune. In fact Boots and the like have offers on the Oral B brushes all the time and do an extra special offer around Christmas time (generally knocking off 50p more than in all previous months). In saying this, I mean stay away from the toothbrushes that are basically a manual brush with batteries in. They will do nothing more than your normal brush but cost a lot, and the toothbrush heads also cost a lot more. 
• With the example of Oral B brushes, the Oral B 1000 does pretty much what the Oral B 5000 (and I've just noticed they have added the word "Triumph" to their latest brush name - fancy). The difference is a clock with a smiley face - something I'm sure a little home arts and crafts could conjure up, and a few "free" brush heads. Considering the difference in price is about 70 pounds, these free brush heads seem to have a significant mark up to the ones you can buy separately.

2. Use a toothpaste with fluoride. At least 1450ppm. It will say this on the side of the box - usually as something fluoride (the something usually being sodium or potassium). Even the really inexpensive toothpastes pretty much all have a good level of fluoride in. (N.B this is the recommended level for adults, children are a different matter. We can also prescribe much higher levels of fluoride if we think you are at a higher risk of getting tooth deca

3. DO NOT RINSE AFTER BRUSHING. The reason we recommend a fluoride toothpaste is because fluoride helps stop bacteria in its tracks. It also hardens the tooth structure. If you wash this off, you pretty much counteract using a toothpaste and so might as well just use a brush and water. Or a stick in fact

4. Mouth wash. This is a tricky one. I like to view mouthwash as a personal preference type thing. Unless we recommend mouthwash as an aid in fighting gum disease (in which case chlorhexidine is the only thing with any proven efficacy), for dry mouth (something I will happily write about if anyone wants advice) or for orthodontic patients (who require more meticulous oral hygiene because they have blobs of metal and Hanibal Lecter type head gear) there is no particular reason for using mouthwash other than to freshen breath.

• We would always recommend an alcohol free mouthwash purely because the less alcohol you can expose your delicate mouth to the better (due to its cancer inducing properties – I’ve put this in brackets so it hopefully makes the “cancer” word less terrifying)
•  If you’re going to use it, wait at least 30-60 mins after brushing for the same reason we say don’t rinse. Ideal would be to rinse at a completely different time of the day so that your teeth are getting another hit of fluoride. Its a bit like applying moisturiser straight after you've already put some on. Its not going to do any harm and it will probably make your skin feel nice, but not as nice as if you wait a few hours and reapply. 
• If you have been recommended to use chlorhexidine this is slightly tricky. Certain ingredients in toothpaste – namely the ones that make it foam – in-activate the stuff in chlorhexidine that makes it work. Sadly it also doesn’t work if there is too much of a plaque layer on your teeth. Therefore pinpointing a time to rinse when it will be effective is tricky but I would say if you are within the 30-60 minute window I mentioned before you should be safe
• For the aforementioned orthodontic (brace wearing) people, or for those who are deemed "high risk" for dental decay - which your dentist can discuss with you - there are a plethora of fluoride mouthrinses. Whilst your dentist can prescribe some which will have a higher concentration of fluoride, you can also pick them up over the counter.

5. Tooth brushes DO NOT clean in between teeth. Gum disease is caused by a build-up of bacteria in between the teeth and below the gum line. The bristles of your brush (or splinters of your stick if you are so inclined) are far too big to get to this area. Therefore to effectively clean your teeth you need to be flossing or using interdental brushes like TePe’s. (I will be writing a separate post about gum disease to explain this in more detail but you get the jist)

I hope this makes sense and that you have picked up some pointers amidst my general annoyance at the general population for their lack of oral cleanliness. In all honesty I should be grateful as it keeps me employed however it would be nice not to feel the need to wear 3 masks and hold my breath to protect me from the halitosis I encounter on a daily basis from whichever dental chair I am leaning over. This is of course not an exhaustive list. There are many other things you can do to get optimum oral hygiene. There is also a lot more you can do to reduce your chances of getting tooth decay and I can of course cover this at a later date. This post is more of a baseline for improving your hygiene rather than the be all and end all of dental decay prevention!

As always, please feel free to ask any questions about toothpaste, toothbrushes, brushing techniques etc etc.

Dental Prevention Toolkit. 

http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_102982.pdf 

This is a very long document aimed at toothworkers however if you have any confusion over what brand of toothpaste/mouthwash contains what ingredients then it is very helpful. 

Below I have provided a bit of a modified contents page of things that might be useful. 

Page number	What you’ll find there
20	Names of toothpaste brands with the amount of fluoride they contain
25	Diet related stuff to help reduce your risk of getting rotten teeth
29	Lists of sugar free medications – they usually say sugar free on the box and most good pharmacists will know which medicines don’t have nasty sugar in, but it is a helpful guide if you’re not sure
There is generally a lot of helpful information in this whole document but I’m hoping there will be very few of you that will rifle through all the jargon as it sort of invalidates the reasoning for me writing this blog so, for my sake, please continue to visit smiles—better!